The definition of health systems is open to interpretation and, depending on individual points of view or values, it can encompass increasing circles of inclusiveness among activities that define a society 16 (pages 7–8). Moreover, the extent to which health systems contribute to the health of populations is disputed 17 . There is nevertheless a general consensus that health systems are at least one significant element among conditions to achieve better health, aside from a wider range of social and political determinants. Importantly, health systems are also core social institutions with intrinsic values beyond their operational effects 18 , trust being an essential cross-cultural value in this respect 19 .

The current definition endorsed by WHO 20 draws from considerations by Murray and Frenk 21 who represent health systems as rooted in 'health action'. A health action is defined as 'any set of activities whose primary intent is to improve or maintain health' and a health system encompasses 'the resources, actors and institutions related to the financing, regulation and provision of health action'. Key to these definitions is the notion of primary intent, which helps set up the boundaries of a health system among all activities whose effects are to improve health. In the analytical framework put forward in Figure 1, core agencies constitute a tripartite model that encompasses the main categories of health services providers classically present in a resource curse environment: governmental health agencies (GOV) represented by ministries of health and dependent agencies at regional and local level; non-profit non-governmental organisations (NPNGO); and the corporate extractive sector (CES), in this case the oil sector represented essentially by transnational companies and their national subsidiaries. This model assumes an early stage of industrial deployment in a resource curse 'enclave' where mostly rural areas would be affected. Later stages of development entail additional complexities due to urbanisation, and will be discussed in a further section. For the sake of simplification, this framework considers only the official providers of health services and it ignores the informal private sector (e.g. private pharmacies), as well as the overlapping category of traditional health practitioners. The latter two categories are popular and probably important in terms of numbers of providers ^b 22 , but their effectiveness is often very low 23 and their range is difficult to quantify, especially in contexts where regulatory policies are lacking or are not enforced. Excluded also from this model are private, regulated, for-profit health service providers, a category which classically operates in urban areas.

Although the three core categories considered in the framework provide services based on 'western' paradigms of healthcare and operate within the same geographical boundaries, they are clearly different in their underlying values, operating principles and self-defined legitimacy, as illustrated by examples in Table 1.

While government agencies are well defined by national policies and laws, the category of NPNGO providing health services is heterogeneous, and includes faith-based and humanitarian organisations, both further categorised as national or international agencies. Their defining values are generally altruism 24 or solidarity, but many international NPNGO adhere also to the operating humanitarian principles defined by the Red Cross and Red Crescent Movement. Furthermore, they operate in a 'humanitarian space' 25 , which can be open to a larger range of actors than international humanitarian organisations. As illustrated in the country examples (Additional file 1 and Appendix 1) and examined in a further section, various types of armed conflicts (ongoing or latent) often characterise resource curse environments, explaining why humanitarian organisations are classically part of this health system, together with other NPNGO and government services. Van Damme et al. 26 have shown the functional antagonism that frequently arises between primary health care and 'emergency medical assistance', recognizing that many situations in the developing world have to accommodate a blend between both paradigms. This conjunction of GOV and NPNGO, including emergency humanitarian organisations, is not an uncommon situation in conflict or post-conflict areas, and there is nothing that makes it specific to a resource curse environment. However, a definitely unique feature of healthcare in a resource curse environment is the real or claimed contribution of the CES to health services. In the absence of independent field data, it is impossible to assess accurately whether the CES makes a quantitatively important difference in terms of the share of services provided or beneficiaries attended. However, the proposed analytical framework intends to address qualitative elements as well. This will be illustrated in the next two sections, which focus principally on the CES.

It has become popular for the corporate sector to be engaged in a number of health actions covering a range of public health endeavours, such as: supporting global or regional health initiatives, sponsoring biomedical research, sponsoring non-governmental organisations or, more directly, financing local health projects. As an example, the case of Exxon Mobil illustrates the diversity of such contributions through its involvement in malaria control 27 . Obviously, health systems are not value neutral. What defines a health system is much more than the sum of all contributions (financial, material, human) to health services. Values, operating principles, legitimacy and governance are especially important to examine here. These issues will be reviewed respectively through the concepts of: corporate social responsibility, social license to operate and international norms.

Corporate social responsibility (CSR) is a distinct and rather recent operating principle originating from the commercial sector. Definitions of CSR are loose ^c, resulting in some confusion over its scope 28 29 . CSR is one among several efforts by private companies toward self-regulation of their social standards. A key feature of CSR initiatives is their voluntary character, falling outside imperatives of legal compliance. Watts 29 (p. 9.22–9.23) lists a number of reasons why CSR initiatives are particularly appealing to the oil industry, including a long history of environmental and human right issues that have tarnished the industry's reputation. A market logic is still the underlying principle here 30 , but CSR addresses concerns over sustainability in all its dimensions: economic, environmental and social 28 . It is useful to distinguish two health aspects of CSR: public health protection of the company's workforce and protection of the 'host' communities. In practice, CSR achievements by extractive industries are much more impressive for the former than the latter beneficiaries, resulting in hubs of local corporate health services offering the highest standards of care, and typically insulated from surrounding communities ^d (Figure 1). This raises important issues of access and equity, and any health system evaluation should specify the exact rules governing access to those insulated health services. Frynas 31 has extensively analysed the motivations, operational effects and developmental linkages of CSR activities in which multinational oil companies claim to be engaged. Motivations seem to be limited to the 'business case for CSR', and include typically: (i) keeping competitive advantage in obtaining territorial concessions; (ii) maintaining a stable and peaceful working environment during critical industrial operations; (iii) improving public relations, often in response to anti-oil protests 32 ; and (iv) improving employees' morale. This has typically lead companies to engage in uncoordinated initiatives, with low developmental impacts, short-term scopes, inadequate community consultation processes, and a preference for infrastructure projects over human capacity building. Some oil companies have evolved toward supporting smaller, grass root self-help projects in collaboration with non-governmental organisations or external development agencies. These initiatives are clear operational improvements, but they fail to compensate for resource curse effects on country governance in the health sector. Frynas concludes that 'Perhaps the key constraint on CSR's role in development is the business case, that is, the subservience of any CSR schemes to corporate objectives'.

Related, but distinct from CSR is the concept of 'social license to operate' (SLO), which is the main operational objective of CSR at community level, giving the corporate industry its share of informal legitimacy and additional operational space (Table 1). How the two concepts of CSR and SLO are supposed to apply to community health and interact through their business-oriented logic is best clarified in an illustrative paper from the British Overseas Development Institute:

"Social investments in local health (...), skills and infrastructure improve the capacity to absorb positive spillovers from and enhance linkages with businesses. The concept of absorptive capacity plays an important and positive role in the theory of FDI and development...

At the same time, businesses also have an incentive to make social investments through partnerships over and above the developmental needs of the local people. Such investments will improve local skills, motivation and health of the local workforce, and thus create more efficient labour inputs and higher quality local suppliers on which business become increasingly dependent. Efficient labour inputs and the quality of local suppliers improve business efficiency, while the consent of the local communities provides a 'social license to operate"' 33 .

Lee and Bialous 34 advocate for a 'more critical debate within and beyond the public health community on the rapid proliferation of CSR initiatives'. Likewise, the same critical debate should address ethical standards and public health objectives of health initiatives initiated by the corporate sector, whenever a 'social license to operate' is at stake.

A last point to consider here is the nature of health governance regimes under which the corporate sector operates in resource curse environments. By essence CSR entails self-regulated norms, and resource curse environments are characterised by poor state governance or deficits in the rule of law. It is therefore important to examine if any international convention would cover norms regulating health systems governance in this context. Article 12 of the International Covenant on Economic, Social and Cultural Rights addresses a number of issues directly relevant to health in resource curse environments. These are specified in General Comment No. 14 issued by the UN Economic and Social Council under 'the right to the highest attainable standard of health' 35 , notably: the principle of non-discrimination in accessibility to health facilities, goods and services; the right to healthy natural and workplace environments; and the recognition of adverse health effects due to 'development-related activities that lead to the displacement of indigenous peoples against their will from their traditional territories and environment, denying them their sources of nutrition and breaking their symbiotic relationship with their lands'. These norms legally apply to signatory States parties, and the private sector is not considered under 'Obligations of actors other than States parties'. Regrettably, transnational corporations thus operate within health systems under the same kind of 'governance gap' as described by Gagnon et al. 36 for international human rights and humanitarian law. Self-regulation under CSR initiatives can probably compensate for some aspects, but certainly not for the essence of this governance gap.

The three core categories of agencies introduced so far in the analytical framework (Figure 1) entertain naturally a number of contractual or more informal relationships with each other. A number of possible configurations (bipartite or tripartite) can be envisaged.

First, GOV and NPNGO interact classically through informal trust-based relationships or relational contracts. However, multilateral development agencies are currently promoting more binding relationships through contracting-out of health services, as indicated in the case of Southern Sudan. The benefits of this experimental approach are still disputed 37 38 . For primary health care services, system-wide effects are open to question 39 .

Second, CES and GOV partnerships in the health sector can be biased by political agendas, at the expense of social achievements. Frynas 31 and Le Billon 40 both give examples pertaining to Angola. Another example of ambiguous partnerships is illustrated by the recent announcement that the current Minister of Health of the Government of Southern Sudan joined the board of advisers of 'Jarch Management Group Ltd.', a US private investment company claiming disputed rights over some oil concessions in the Greater Upper Nile region 41 . The company statement does not mention if the rationale for the partnership with the Minister of Health entails health-oriented CSR projects in the contested area.

Third, the relationship between CES and NPNGO has some underlying complexity. For example, oil companies are unable and unwilling to undertake comprehensive development projects and they are clearly looking for partnerships and joint initiatives to achieve their corporate social responsibilities 42 43 . For extractive industries in general, this strategy has been formalised as a 'tri-sector partnership model of social management' between the government, civil society organisations and the corporate business 33 . From the corporate sector's side, this is described as a 'relatively innovative management technique' for the 'complex social issues relating to FDI in the extractive industries', responding in part to 'the needs of companies to operationalise their corporate social responsibilities at reasonable and sustainable cost' 33 . At international level, a scaled up version of the model ('Tri-Sector Partnering') has been promoted by the World Bank Group as "a management tool that delivers benefits to communities affected by investments and, thus enhances the informal, social 'license to operate' of the investing companies" 44 .

With the notable exception of international humanitarian organisations, the 'tri-sector partnership model' promoted by the corporate sector and multilateral development agencies thus draws from the same categories of actors that define the core elements of the formal health sector in a resource curse environment.

Whether implemented under the umbrella of bilateral or multilateral development agencies, the place of ODA-financed health programmes in this context is ambivalent. They dwell upon the core categories of the tripartite health system model illustrated in Figure 1, and borrow similar values to some extent. However, ODA policies represent distinct core values, typically (in the case of bilateral agencies) reflecting the foreign policy and national interests of the country or alliances that they represent 45 . This is what distinguishes ODA programmes from humanitarian assistance, the latter remaining within the remit of soft-power foreign policy 24 . Yet, humanitarian assistance itself can be instrumental to foreign policy, as shown by Middleton and Keefe 46 in the example of Sudan. Furthermore, ODA policies fulfil multisectorial objectives, and thus represent also the commercial interests and defining values of the transnational companies with which governments enter into partnership at the level of higher politics.

The tripartite health system framework described in previous sections is a dynamic model and it is naturally bound to evolve. Demographic pressure and urbanisation are obvious motors of change for local communities (especially indigenous populations) impacted by the resource curse, either through in site infrastructure developments or, more commonly, through migration toward booming urban areas. To different extents, the four areas examined in this paper are undergoing rapid demographic changes, which result in increased and mostly unregulated urbanisation. This is obvious for Luanda, the capital of Angola, and for Port Harcourt, the capital city of Rivers State, Nigeria. In the Doba basin of southern Chad, the oil extraction area of Komé has doubled its population since 1993 47 . In Southern Sudan, state capitals like Juba, Wau and Malakal are set for rapid urban growth 48 . Aside from voluntary movements of post-conflict returnees, examples abound to show how oil extractive industries are disruptive of traditional lifestyles and rural communities, and how they constitute a powerful drive toward urbanisation, independently of frequent territorial seizures and forced displacements. The reasons are varied and synergistic, including: environmental degradation; persistent conflicts; loss of agricultural assets and of food security; loss of cultural identity; demographic and social pressure from the in-migration of job seekers 9 , and other societal changes related to new job markets ^e 13 . Even from a strictly economic perspective, extractive industries can have imbalanced impacts, depending on the geographical level of analysis. In this context, te Velde 33 acknowledges that '...a cost-benefit analysis of an FDI project is likely to lead to different assessments depending on the target group, e.g. national economies versus local communities'.

Harpham and Molyneux 49 have reviewed evidence showing that sub-Saharan Africa is actually the theatre of an 'urban penalty' phenomenon, as far as secular health improvements are considered. Infant mortality rates in particular have risen in small and medium-sized African cities, part of the reason being probably the HIV/AIDS epidemic. Thus, assessments of actual effects of oil extraction projects on 'host' communities should take into account longer-term effects due to urbanisation and they should consider health outcomes and impacts occurring at the actual sites of relocation, particularly when this entails exposure to new social contexts and different determinants of health.

The association between oil extraction and armed violence is well established, and it is classically considered one of the root causes of the resource curse. First, interstate conflicts are a recurrent theme in the history of oil extraction 29 (p. 9.8–9.10). Second, most of the sub-Saharan countries endowed with substantial oil reserves have been the site of recent or protracted conflicts and violence of some sort. These include civil wars, inter-ethnic conflicts, interstate disputes and military interventions, political repression, human rights abuses 50 51 52 . Third, oil booms frequently result in the misappropriation of oil revenues by rulers of rentier states, bloating the share of the national budget allotted to military expenditures ^f and/or to the weapons industry. Sudan 53 (p. 18) and Chad 54 (p. 10) are classical examples. Fourth, there are complex relationships between transnational oil companies and the security apparatus of their host governments 29 (p. 9.18–9.19), leading in extreme cases to their complicity with security forces in perpetrating human rights abuses 32 55 . Finally, the accumulation of adverse political, economic and social effects brought about by oil extraction at local level can create grievances that lead to armed conflict 15 . A typical example is the ongoing political violence in the Niger Delta region 56 .

As a particular form of armed conflict, civil war has been studied extensively, producing a rich and at times inconclusive body of academic literature. Definitions of civil war are not standardised, but they generally entail a specified threshold number of casualties over a time period within a defined context of rebellion 57 58 . The peculiar importance of civil war here is that adverse health effects are considerable and extend well beyond the period of active warfare 57 .

Using econometric analyses, Collier and colleagues 59 60 have examined the links between natural resources and civil wars. They claim that there is a direct and highly significant relationship between national dependence upon primary commodity exports (oil in particular) and the risk of internal conflict in low-income countries. In an attempt to explain this relationship, Collier and Hoeffer 61 argue that the initiation of rebellions is better predicted by the funding opportunities offered by access to natural resources, than by proxy indicators of social grievances. This notorious theory of 'greed vs. grievance' (more appropriately summarised later by their authors as 'atypical opportunities' vs. grievance) addresses an important development issue. However, the theory has been criticised by independent evaluators for its 'lack of appropriate conceptual and empirical framework' ^g 62 and its relevance has been disputed by several scholars 29 63 64 . Ross 12 65 66 provides in-depth reviews of the large body of research available on the links between natural resources and civil wars, explaining why Collier and Hoeffler's findings are actually not robust. Ross's thorough analysis points out to a number of methodological issues (in particular around semantic and parametric definitions) and to a variety of plausible causal mechanisms which have been insufficiently addressed. I would add that the extent to which parameters reflecting grievances have been explored in this body of literature is remarkably poor. For example, in the regression model tested by Collier and Hoeffler 61 , none of their proxy measures for grievance relates to social conditions in general, and to health in particular. Using Shell in Nigeria as a case study, Rieth and Zimmer 67 have shown that a transnational company can evolve under the pressure of civil society organisations, toward internalisation of social norms leading to an active role in conflict prevention. Longitudinal observations of this sort suggest useful methodological complements or alternatives to the common cross-sectional parametric approach underpinning the bulk of the 'greed and grievance' literature.

Having reviewed the evidence for armed violence as a leitmotiv in the landscape of oil extraction, the key question is: to what extent does violence contribute to adverse health effects in a resource curse environment? Coupland 68 has clarified the conceptual background and shown that armed violence contributes to health impacts in two ways. The first (and obvious) element is the direct effects of trauma from weapons. The second element is people's insecurity, the latter term being understood in its broad sense encompassing the systemic effects of violence on communities and health services, and quite distinct from national or international security issues. Furthermore, violence as a constitutive element of a resource curse environment justifies the presence of humanitarian actors or other substitutive health organisations, and thus contributes to the perpetuation of a fragmented palliative health system, with indirect effects on the distribution of human resources for health. In their review of the role of health in internal stability and failed states, Lee and McInnes 69 conclude that there is yet no direct evidence to show that 'ill health can contribute to internal instability' or 'whether improved health and better healthcare provision can stabilise states'. It is thus premature to describe the relationship between violence and ill health as a vicious circle in a resource curse context, although lack of access to health services can certainly constitute a major and legitimate source of grievance.

There are at least three processes through which adverse health effects of industrial development projects can be mitigated at community level, and which would apply directly to oil extraction. These are: health impact assessments, consultations with local communities, and long term monitoring. A Health Impact Assessment (HIA) is an essential part of the broader Environmental Impact Assessment (EIA) process that is now considered standard practice for project proposals submitted to international development agencies 70 . Lee et al. 71 see HIA as a tool for public health to influence foreign policy. The authors summarise the positive effects of HIA in general by their capacity to (i) raise awareness among decision-makers, (ii) assess the potential impact of specific proposals on populations' health and (iii) improve and optimise the outcome of proposals. From the corporate side, EIA is seen as 'a tool to secure the social license to operate' and a strategy to advance tri-sector partnerships 72 . HIA are less likely to improve the social components of projects (including health issues), compared to strictly environmental issues addressed by EIA 72 . Furthermore, current practices in carrying quantitative HIA suffer from insufficient standardisation and methodological uncertainties about their reliability and validity 73 .

If one considers that the 'Chad Cameroon Petroleum Development and Pipeline Project' (CCPDPP: see Appendix 1) is a model of environmental and health impact mitigation in oil extraction (due to the oversight of the World Bank Group), the weight given to public health concerns and to HIA as a guarantee of best practices is at best disappointing. While the preliminary HIA had arguably induced some improvements in specific health outcomes (e.g. malaria, traffic accidents, minor sexually-transmitted infections), broader systemic health issues raised by the international panel of experts appointed by the World Bank were ignored or dismissed by the Consortium of corporate stakeholders 74 . One of the appointed experts asserts that: '...it appeared that in this project decisions were based largely on cost and profit considerations, giving only passing attention to environmental and social aspects, and little or no decision-making power to the affected populations' 74 . Such 'decision making power' is often confounded or misrepresented by the corporate industry as the outcome of 'consultations', another standard practice often included in the CSR package of activities. As pointed out by analysts of the impact of extraction industries on indigenous communities 75 , 'consultations are fundamentally flawed as a mechanism to assure that indigenous people rights are fully respected'. The authors point out frequent reasons, including the facts that: (i) companies and governments bias consultation toward obtaining local acceptance of project, (ii) companies and governments fail to disclose critical information to communities about petroleum impacts and (iii) communities are not advised that they are being 'consulted'. In addition, there is a risk that prospects for improvement of health services (typically infrastructure projects) would be used as bargaining power during any consultation process. It should be kept in mind that, ultimately, concerned communities have no veto right upon an industrial project that would impact their territories and threaten their identity, a striking asymmetry of power that is implicitly acknowledged by the World Bank 76 through the existence of a detailed 'involuntary resettlement' policy, however strict are its written safeguards.

Finally, longitudinal monitoring of health outcomes and impacts of projects such as oil extraction should be standard procedures. Taking again the CCPDPP as an alleged model, there is much scope for improvement in practice, with a need for systematic baseline studies and pre-established public health surveillance mechanisms.

Nigeria, the world's eighth-largest oil exporter, has a three-tiered federal government system with 36 states divided into 774 local government councils (LGC). The country gained independence in 1960 and started oil exploitation in 1958, essentially in the Niger Delta region, where four states (Akwa Ibom, Bayelsa, Delta and Rivers) account for most of the national production. In spite of such wealth, this is a region where the GNP per capita and educational levels remain below national average, and 70 percent of its 20 million people are living below the poverty line ^j 63 90 . The environmental impact of oil production has been disastrous, due to frequent oil spills and to the common practice of gas flaring 43 90 91 92 . Deforestation and quarrying activities to meet the needs of rapid and uncontrolled urbanisation 93 add to the burden of environmental degradation. Livelihoods have traditionally relied upon fishing and farming. These vital resources are now severely compromised by the effects of water pollution, degradation of arable soils and land seizure 90 . Conflict and violence have been persistent since the 1990's, due to multiple and intricate factors 22 63 . This has created a climate of rebellion and insecurity, culminating recently with the frequent kidnapping of foreign oil workers, a threat to the sustainability of industrial investments 94 . Political repression 56 and massacres of rebellious communities by official authorities are well documented, for instance the Umuechem massacre of 1990 43 . The Niger Delta region is more affected by HIV infection than any other region or zone in the country, due to the combined effects of poverty, urbanisation, unemployment, and migration of foreign or national labourers 95 .

As shown by Human Rights Watch 56 in the Rivers State, corruption is overwhelming in most of the LGCs surveyed. Social services (health and education) and facilities run by LGC authorities in the region have collapsed 93 . Itinerant drug sellers and traditional healers are frequently used as substitutes for public healthcare 22 . Throughout the country, primary health care services are under the responsibility of LGCs, but in practice, they are delivered in large part by non-state providers, in particular by faith-based organisations affiliated with the Christian Health Association of Nigeria 96 . Due to increasing levels of violence, international humanitarian organisations such as Médecins Sans Frontières 97 maintain an operational presence, mostly in Port Harcourt, the capital of the Rivers State. The role of transnational oil corporations and their subsidiary companies in contributing to community development programmes in general ^k 29 , and in the provision of health services in particular is unclear and controversial. Shell for instance is upbeat about its involvement in immunisation campaigns, HIV/AIDS awareness campaigns, and support to health facilities and services 42 98 . However, independent evaluations 22 32 43 as well as anecdotal press reports show that the reality on the field is far from matching such claims of social achievements. As a symbol of two diverging worlds, the contrast is blatant between the quality of health care offered at the Shell hospital inside of the company compound in Port Harcourt, and the derelict state of public health facilities in the region 99 .

With huge reserves of mostly offshore oil and a population of 12.4 million, Angola is one of the richest countries in Africa. Yet, it ranks poorly in terms of social development and it has the highest level of inequality among oil and gas producers. At least one third of Angola's population resides in shantytowns 100 with very limited access to clean water 54 . The year 2002 marked the end of 27 years of civil war between UNITA rebels funded by the diamond trade and the governing MPLA financed by oil exports 50 100 . Oil revenues have sustained a war effort against the armed separatist rebellion, which claims sovereignty over the Cabinda enclave, a territory including 60 percent of Angola's oil assets 40 . In August 2006, a peace agreement was signed between the government and rebel forces in Cabinda.

The ruling elite of Angola is opaque and largely unaccountable about national oil revenues amounting to several billion US$ per year. The country is still very much dependent on foreign aid for the vital sectors of health, food relief and emergency assistance. The transition from humanitarian relief to reconstruction has been slow, partly due to obstructions to the work of aid agencies by the Angolan government. The role of oil companies in the social sector is troubling, and Le Billon 40 could comment that: "As for financial support for social, economic and humanitarian projects, oil companies have become one of the main sources of private funding. There is some concern, however, regarding the legitimacy and the political nature of some donations, such as those benefiting 'well-connected NGOs'...".

Compared to the Niger delta, Angola thus offers a more straightforward example of the resource curse, devoid of major local and environmental dimensions, while the country at large is still relying heavily on foreign aid and relief agencies for the provision of basic services. For example, excluding landmines action, Angola has appealed for a total of US$ 17,468,992 in foreign emergency assistance in 2007 101 .

With the assistance of the World Bank Group (WBG), oil fields have been exploited since 2004 in the Doba basin of southern Chad, through an impressive and elaborate public-private partnership between a consortium of transnational companies, and the governments of Chad and Cameroon. The project includes the development of three oil fields in southern Chad, a 1000-km underground pipeline running through Cameroon, an offshore export terminal, and the construction or rehabilitation of a large number of ancillary infrastructures alongside 11 . The 'Chad Cameroon Petroleum Development and Pipeline Project' (CCPDPP) is a major investment, and an endeavour by the WBG and partners to set up a model of economic, political and social achievements in poverty reduction through oil exports. While unrest and conflict have not specifically reached this southern region of Chad, civil society organisations have expressed strong reservations about the merits of the project, with regard to the endemic climate of corruption, poor governance and political repression 9 102 . Accordingly, the WBG has put monitoring processes in place and, to some extent, it has held to its strong commitment to set a precedent in social and environmental standards. After more than three years however, social achievements of the project at community level are disappointing, despite claims by the WBG that large public constructions are well underway in the cities of Doba and Bébédja 103 . More importantly, the political and economic safeguards that the WBG had required to avoid a resource curse are being jeopardised, and expectations of improved governance from national authorities are not met ^l 9 102 104 . One important adverse element stressed by external analysts (see for instance 11 ) is that, while oil production capacity has been established ahead of schedule, institutional capacity-building projects have badly lagged behind.

The health sector is poorly developed in Chad, due to a lack of qualified medical staff, a lack of management skills at all levels, and a concentration of health services in urban areas 105 . The question therefore is whether the CCPDPP will help improve health outcomes in general, and a deficient health system in particular. As noted by Gary and Karl 102 , the Chadian revenue management law of 1998 is 'vague regarding priority sector and regional spending', lacking any '...directive about whether money may be spent, for example, on primary health clinics in rural areas or state of the art hospitals in the capital'. In 2005, this law which was designed to offset resource curse effects was unilaterally abrogated, and renegotiated with the World Bank under more favorable terms for discretionary use of oil revenues by the Chadian government 106 . There are anyway no signs that the existing public health infrastructure has been improved in the project area 11 , despite initial warnings by a panel of experts who observed a 'shocking disparity in affluence [between the consortium's health facilities and local hospitals], calling into question the ethical values inherent in this project' 74 . One of the alleged strengths of the project is a community health outreach programme addressing in priority HIV/AIDS, sexually transmitted infections, and malaria 107 . The focus on the former two conditions is critical since the CCPDPP entails an influx of job-seekers and truck drivers, most of them single or unaccompanied men, while up to 50% of prostitutes in some areas around the pipeline are infected with HIV 13 74 108 . The malaria-control program and the HIV/AIDS prevention campaign are both run by local non-governmental organisations 107 . The independent International Advisory Group 109 (7^th and 9^th statutory missions) has repeatedly noted the absence of baseline studies and delays in setting up monitoring mechanisms, in particular with respect to HIV/AIDS prevalence in the project areas. Health impacts of the project will therefore be difficult to determine.

A glance at a concession map 110 reveals outright how much the geographical and human landscape of southern Sudan is and will be affected by oil extraction and by the presence of transnational companies. After a devastating conflict between the north and the south spanning about 50 years, a Comprehensive Peace Agreement (CPA) was finally signed on January 2005 between the Government of Sudan (GOS) and the Sudan People's Liberation Movement (SPLM). This peace settlement is fragile, due to ongoing tensions between political factions; disputes over the final territorial borders between the Government of National Unity (GNU) and the recently established Government of Southern Sudan (GOSS); and the uncertain fate and livelihoods of returnees, most of them compelled to settle in fast expanding urban areas 111 . Access to oil fields has been one of the major issues in the protracted north-south conflict 54 112 , resulting in loss of livelihoods, forced displacements, massive violations of human rights, and ultimately to dramatic health impacts and to the destruction of many rural communities 113 . Evidence for the complicity of some transnational companies with helping the GOS in repeated attacks on civilian populations is overwhelming 55 53 (part 2). The most publicised case involved Talisman Energy, the largest western company involved in Sudan at the time, which ultimately withdrew from its oil operations in the country in 2003, in response to shareholders' concerns over human rights abuses. During the last years of the north-south conflict (2000–2004) and under implicit or explicit political agendas 46 114 , the international community spent huge amounts of money in humanitarian aid, essentially as food distributions. The direct monetary contribution to health through this process barely exceeded 5% of the total. The situation of the health sector has been described by the newly established Minister of Health as "dismal, with a system that is severely fragmented across multiple actors and numerous vertical programs, largely unregulated, inefficient, under-funded, with a derelict infrastructure and an impoverished and internally distorted work-force"^m 115 . As an illustration of the cumulative impacts of the conflict, a recent Sudan Household Survey showed that Southern Sudan has one of the highest Maternal Mortality Rates in the world (2030 per 100,000 births). The World Bank has been housing a Multi Donor Trust Fund to which the Ministry of Health of the Government of Southern Sudan 115 has submitted a three-years proposal for a health sector development programme. The programme is based on a two-track strategy covering rapid and long-term interventions respectively. The fast track relies on contracting firms or NGOs to implement a pilot project including: the management of large hospital services, the reform of the existing civil health services, and the expansion of basic health services in underserved areas. Given that the long-term health policy of the World Bank for Sudan in general is definitely directed toward the introduction of cost recovery and the privatisation of the health sector 116 (p. 122), it is likely that the GOSS will be compelled to follow the same footsteps. Meanwhile, during its first Health Assembly in June 2007, the GOSS has adopted resolutions towards a decentralised health care system 117 . The exact contribution of the oil industry in the rehabilitation of the public health sector, either in kind or as a contribution to health financing is unknown, although several referral health facilities of South Sudan are known to have been established or rehabilitated by private oil companies. Talisman Energy was one of them 53 (Part 2, p. 26–29). Lessons from the environmental tragedy in the Niger delta do not seem to have been learned in Southern Sudan. For example, recent reports indicate forceful evictions and ongoing environmental degradation by oil companies in the Sudd Wetlands, the world largest swamplands of the world. Cattle livelihoods are being lost. Soils and drinking water are contaminated by saline water injected to maintain pressure of the oil reservoirs, and by the dumping of industrial waste in swamp areas liable to flooding 118 . One resident was quoted saying: "If the government ignores us we will go Nigeria-style [struggle]".